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Left-atrial pressure monitoring continues to be of value in cardiac surgery of the high-risk patient. Complications are fortunately low and include haemorrhage following catheter removal and retained catheter fragments. A simple and safe technique is presented to retrieve retained catheters using a rigid bronchoscope and avoiding the need for resternotomy.
Thin-caliber (4.9 and 6.3 mm) flexible bronchoscopes already provided with a suction button have been modified by adding an air/water button for the control of air insufflation and water irrigation; the channel used is the biopsy-suction one. With the aid of this instrument, several pathologies can be studied and treated, under adverse conditions such as esophageal or recto-sigmoidal stenosis, hematuria in polytraumatic patients, residual stones in patients carrying a T-tube, acute respiratory obstructions, etc.
Rhodotorula rubra was isolated from bronchoscopy specimens from 11 patients. An investigation of the bronchoscopy equipment and the bronchoscopy suite revealed contamination of the suction channel with R rubra, as well as potentially pathogenic bacteria. Disinfection control methods included gas sterilization of the bronchoscope and the institution of an alcohol and air flush through the suction channel to allow complete drying of the scope between each patient use. We have had no further isolates of R rubra from bronchoscopy specimens since these measures were instituted, and repeat cultures from the suction channel have been negative.
During a 6-month period, two genetically distinct clones were isolated from 65% of patients with Pseudomonas aeruginosa isolated from bronchial specimens obtained during or after bronchoscopy. This epidemic was due to contamination of bronchoscopes by washing machines. After reintroduction of manual disinfection of endoscopes, a significant decrease in the incidence of the epidemic clones was observed, but the incidence of nonepidemic P aeruginosa did not change. The distinction between sporadic and epidemic cases was possible only with the use of a molecular typing method (ribotyping).
A laboratory assessment of a ventilating bronchoscope incorporating automatic flow interruption suggests that it will safely adequate ventilation.
Droperidol has been reported to cause bronchodilatation but its mechanism(s) of action is unknown. We have evaluated the spasmolytic effect of droperidol on histamine- and serotonin (5-HT)-induced bronchoconstriction in dogs. Bronchial cross-sectional area was assessed with a superfine fibreoptic bronchoscope. Twenty-eight mongrel dogs were allocated randomly to one of two groups (histamine and 5-HT) to receive either histamine or 5-HT to induce bronchoconstriction. Changes in bronchial cross-sectional area were presented as percentage of basal bronchial cross-sectional area. Continuous i.v. infusion of histamine 500 micrograms kg-1 h-1 or 5-HT 500 micrograms kg-1 h-1 decreased percentage bronchial cross-sectional area by 46.4 (14.3)% or 68.9 (13.7)%, respectively. In both groups, droperidol reversed bronchoconstriction in a dose-dependent manner. In the histamine but not in the 5-HT group, plasma adrenaline and noradrenaline concentrations increased significantly after i.v. droperidol. In addition, propranolol antagonized droperidol-induced relaxation in the histamine but not in the 5-HT group. Our data indicate that the spasmolytic effect of droperidol on canine airway was caused, at least in part, by both catecholamine releases and 5-HT receptor antagonism.
Although tracheostomy tube displacement is uncommon, the management is often difficult and the associated mortality is high. It is important to ensure that the airway is secure and then either replace or reposition the tracheostomy tube. This case report describes the use of an Aintree intubation catheter (C-CAE-19.0-56-AIC, William Cook Europe, Denmark) mounted on an intubating fibre-optic bronchoscope (11302BD1, Karl Storz Endoskope, Germany) to reposition a partially displaced tracheostomy tube.
The fiberoptic bronchoscope is an invaluable aid in the difficult endotracheal intubation. Its successful use with three patient groups is described: those with soft-tissue contractures of the mouth or neck; those with severe fractures of facial bones and/or mandible; those with unstable fractures or fracture-dislocations of the cervical spine. Fiberoptic bronchoscopy is felt to be the technique of choice when intubation is difficult, especially when there are contractures or deformities of the larynx, manidible, or cervical spine.
Transbronchial lung biopsy through the fiberoptic bronchoscope was done in 15 patients, and adequate pulmonary tissue was obtained in 14 (93.3%). A pathologic diagnosis was made in nine patients (64.3%), and through direct histologic examination of lung tissue in two patients certain disease entities were excluded, thus significantly influencing treatment. There was no significant hemorrhage and only one small pneumothorax occurred.
The Freeman-Sheldon syndrome is a congenital disease primarily affecting the facial, limb and respiratory muscles that give rise to classical clinical features including typical whistling face and short webbed neck associated with difficult intubation. We present successful awake nasotracheal intubation in a 6-year-old patient with typical clinical features of Freeman-Sheldon syndrome by using fiberoptic bronchoscope on two separate occasions.
BACKGROUND: The purposes of this study were to further identify the hemodynamic responses to orotracheal intubation in children, using a fiberoptic bronchoscope (FOB) and a direct laryngoscope (DLS), and to validate whether the FOB can attenuate the hemodynamic response to orotracheal intubation compared with the DLS. METHODS: Forty-three children, ASA PS I-II scheduled for elective plastic surgery under general anesthesia requiring orotracheal intubation were randomly allocated to either the DLS group (n = 20) or the FOB group (n = 23). Noninvasive systolic blood pressure (SBP) and heart rate (HR) were recorded before (baseline values) and after anesthesia induction (postinduction values), at intubation and every minute for the first 5 min after intubation. The maximal values of SBP and HR during the observation were also recorded. The product of HR and SBP [rate pressure product (RPP)] at each time point was calculated. RESULTS: In the DLS group, SBP, HR, and RPP at intubation and 1 min after intubation were significantly higher than postinduction values, but did not exceed baseline values. In the FOB group, SBP, HR, and RPP at intubation increased significantly compared with baseline and postinduction values. In the two groups, the maximal values of SBP, HR, and RPP during the observation were significantly higher than baseline values. Except for the HR at intubation, there were no significant differences in other hemodynamic parameters during the observation and the time required to reach maximal values of SBP, HR, and RPP between the two groups. CONCLUSIONS: Orotracheal intubation using FOB and DLS in children may cause similar increases in SBP and HR. Compared with the DLS, the FOB had no advantage in attenuating the hemodynamic responses to orotracheal intubation.
A 27-year-old male visited the outpatient clinic of our hospital with the chief complaints of fever, right chest pain and shortness of breath. He was admitted to our hospital for detailed examination of the right hydrothorax. The pleural effusion obtained by thoracocentesis was exudative and negative for Mycobacterium tuberculosis. Since the titer of adenosine deaminase in the pleural effusion was abnormally high, antitubercular therapy was started under suspicion of tuberculous pleuritis. Thereafter, the patient's subjective symptoms and blood parameters improved. Necrotic tissues were obtained by pleural biopsy using the Cope needle. In order to make a definitive diagnosis, pleural biopsy was performed thoracoscopically. White tubercular lesions with a smooth surface were sparsely distributed on the pleura. Histopathologically, these lesions were characterized by central areas of caseous necrosis surrounded by epithelial cells and Langhans' giant cells. Therefore, they were considered to be granulomatous lesions. The patient was given a diagnosis of idiopathic tuberculous pleuritis, and was treated with four antitubercular drugs in combination. His clinical signs subsided, and he was discharged. This case indicates that the examination of the inside of the pleural cavity with a flexible bronchoscope, instead of thoracoscope, under local anesthesia is useful to diagnose patients having tuberculous pleuritis.
A system for imaging occult bronchogenic carcinoma by the fluorescence of previously-injected, tumor-specific compound hematoporphyrin-derivative has been assembled and successfully used to locate a tumor 1 mm thick. The violet excitation source is a krypton ion laser coupled to fused quartz fiber light conductor. An electrostatic image intensifier attached to a standard flexible fiberoptic bronchoscope provides a bright image even at relatively low irradiance. A red secondary filter rejects most reflected background and autofluorescence. Sensitivity and contrast capability of the system should permit detection of a tumor less than 0.1 mm thick.
Contamination of bronchoalveolar lavage specimens by environmental mycobacteria in hospital water supplies may lead to diagnostic confusion, particularly in immunocompromised patients. Mycobacteria may become concentrated in the tubing of bronchoscope disinfecting machines. It is very difficult to eradicate these organisms once contamination has occurred.
CT bronchus sign (BS) designates a bronchus leading directly to a peripheral pulmonary lesion. The objective of this investigation is to determine the contribution of BS-guided bronchoscopic multiple diagnostic procedures (BMDPs) to the diagnostic yield of solitary nodules or masses (SPNMs) suspected of pulmonary carcinoma (PC). A prospective study was carried out in 92 patients with a 2-5 cm diameter SPNM at the level of third to fifth bronchial branching and without endobronchial tumors. Within 10 days after 2-mm CT scans were done, in each of 92, bronchial washing (BW), brushing (BR), transbronchial needle aspiration (TBNA) and transbronchial lung biopsy (TBB) were performed respectively, via fiberoptic bronchoscopy (FB) under fluoroscopic guidance. In 40 (82%) of 49 with BS and in 19 (44%) of 43 without BS, FB established the diagnosis (p < 0.01). In 84 cases of PC, BW, BR, TBNA and TBB provided the diagnostic yields of 4% (3), 26% (22), 57% (48) and 49% (41), respectively; the combined yield reached 68% (57). A metastasis and a tuberculoma were diagnosed exclusively by TBB, and TBNA, respectively. All differences of diagnostic yield except that between TBNA and TBB (p > 0.05) were determined to be significant (p < 0.05). Thoracotomy verified diagnosis in 48 of 59 cases diagnosed and 19 of 33 undiagnosed by FB, and various tissue biopsies or clinical follow-up in 11 diagnosed and 14 undiagnosed by FB. The above data suggest that in the diagnosis of PC as a SPNM at the level of third-fifth bronchial branching, combining the guidance of CT BS, and BMDPs under fluoroscopic guidance can increase the yield considerably.
We performed a prospective observational cohort study of the epidemiology and etiology of nosocomial pneumonia in 358 medical ICU patients in two university-affiliated hospitals. Protected bronchoscopic techniques (protected specimen brush and bronchoalveolar lavage) were used for diagnosis to minimize misclassification. Risk factors for ventilator-associated pneumonia were identified using multiple logistic regression analysis. Twenty-eight cases of pneumonia occurred in 358 patients for a cumulative incidence of 7.8% and incidence rates of 12.5 cases per 1, 000 patient days and 20.5 cases per 1,000 ventilator days. Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, and Hemophilus species made up 65% of isolates from the lower respiratory tract, whereas only 12.5% of isolates were enteric gram-negative bacilli. Daily surveillance cultures of the nares, oropharynx, trachea, and stomach demonstrated that tracheal colonization preceded ventilator-associated pneumonia in 93.5%, whereas gastric colonization preceded tracheal colonization for only four of 31 (13%) eventual pathogens. By multiple logistic regression, independent risk factors for ventilator- associated pneumonia were admission serum albumin <= 2.2 g/dl (odds ratio [OR] 5.9; 95% confidence interval [CI] 2.0-17.6; p = 0.0013), maximum positive end-expiratory pressure >= 7.5 cm H2O (OR, 4.6; 95% CI, 1.4 to 15.1; p = 0.012), absence of antibiotic therapy (OR, 6.7; 95% CI, 1.8 to 25.3; p = 0.0054), colonization of the upper respiratory tract by respiratory gram-negative bacilli (OR, 3.4; 95% CI, 1.1 to 10.1; p = 0.028), pack-years of smoking (OR, 2.3 for 50 pack-years; 95% CI, 1. 2 to 4.2; p = 0.012), and duration of mechanical ventilation (OR, 3. 4 for 14 d; 95% CI, 1.5 to 7.8; p = 0.0044). Several of these risk factors for ventilator-associated pneumonia appear amenable to intervention.
Primary lung carcinoma adjacent to the trachea and paratracheal nodal metastasis without evidence of the primary tumor or airway invasion require invasive surgical procedures to obtain adequate diagnostic tissues. Adequate diagnostic tissue was obtained in 3 of 5 patients with paratracheal masses by means of a bronchoscopic needle aspiration technique. There were no complications.
Artificial and animal lung models initially were used to investigate the removal of foreign bodies from the tracheobronchial tree with the flexible fiberoptic bronchoscope. Different extraction instruments (claw, basket, forceps, and balloon catheter) were passed separately through the channel of the bronchofiberscope, and tested for usefulness prior to human application. The Fogarty balloon catheter served as a valuable aid in dislodging impacted objects so that the operator could then grasp them with the claw, basket or forceps. The wire claw recovered many of the metallic and organic objects, the wire basket was successful in retrieving only the bulky objects and the forceps (ACMI) was effective in capturing all of the metallic foreign bodies. These techniques, developed in our laboratory, are now being used to augment rigid bronchoscopy in the removal of foreign bodies from adults and older children. At the present time fiberoptic foreign body removal is not recommended for pediatric cases because of the small diameter of the trachea and glottis in infants and young children.